Assessment Task: Case Study
Mr James Saunders a 36 year old single male has been admitted to your ward with exacerbation of his asthma. His hearing is moderately impaired and he wears hearing aids in both ears. After introducing yourself, you notice that his respiratory rate appears moderately fast at 28 breaths per minute.
Mr Saunders has always struggled with the disease since childhood and that during early spring he tends to get worse, especially on windy days. He reports not feeling ‘too bad' at present and that this degree of shortness of breath is ‘pretty usual' for him. He denies coughing up any sputum, and states that he hasn't any chest pain.
Mr Saunders appears flushed, and is speaking in short sentences. You take his vital signs and note a blood pressure of 140/70 and his oxygen saturation rate is 90% on room air. When you inspect Mr Saunders chest your note moderate use of accessory muscles and on auscultation there is wide spread respiratory wheeze.
Describe a detailed focused health assessment of Mr Saunders based on his current presentation of asthma. This essay should address the following points in discussion:
• Describe the area of focused assessment to be considered for Mr Saunders stating the rational for such a choice.
• Describe the normal assessment parameters of the assessment identified in the previous question
• Describe how Mr Saunders's presentation deviates from these normal assessment parameters explaining the pathophysiology associated with each relevant symptom presented in the above case study.
• Mr Saunders presents with a history of asthma, from your research on asthma identify any further areas to be investigated and what further assessment needs to be conducted to collect more data.
• Clustering pieces of data enable problems to be identified: identify problems that may apply to Mr Saunders.
• Identify potential risk or precipitating factors that could contribute to Mr Saunders experiencing asthma in the future.